“They Destroy the Reproductive System”: Exploring the Belief that Modern Contraceptive Use Causes Infertility

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03/04/2019 12:00 am

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A common reason for nonuse of modern contraceptives is concern about side effects and health complications. This article provides a detailed characterization of the belief that modern contraceptives cause infertility, and an examination of how this belief arises and spreads, and why it is so salient. We conducted focus group discussions and key informant interviews in three rural communities along Kenya’s eastern coast, and identified the following themes: (1) the belief that using modern contraception at a young age or before childbirth can make women infertile is widespread; (2) according to this belief, the most commonly used methods in the community were linked to infertility; (3) when women observe other women who cannot get pregnant after using modern contraceptives, they attribute the infertility to the use of contraception; (4) within the communities, the primary goal of marriage is childbirth and thus community approval is rigidly tied to childbearing; and, therefore (5) the social consequences of infertility are devastating. These findings may help inform the design of programs to address this belief and reduce unmet need.

Reducing unmet need for modern contraceptives remains a top priority for organizations working in global health and international development. Couples can use modern contraceptives to delay the onset of childbearing, to space births, and to limit completed family size. This in turn can lead to benefits at the individual, family, community, and national levels, including reduced maternal, infant, and child mortality; the reduction of poverty; increased education for girls and boys; improvements in the status of women; and economic growth (Canning and Schultz 2012; Cleland et al. 2012; Conde‐Agudelo et al. 2012; Bongaarts 2016; Miller and Babiarz 2016).

Nevertheless, the actual level of modern contraceptive use remains well below its potential. This is especially true in sub‐Saharan Africa, where the modern contraceptive prevalence rate lags behind other regions of the world and unmet need for modern contraceptives remains high (Sedgh and Hussain 2014). Accordingly, the UK Department for International Development, the Bill and Melinda Gates Foundation, and other organizations in 2012 adopted the goal of increasing the number of women using contraception by 120 million by the year 2020 (Brown et al. 2014). The United States Agency for International Development (USAID) set a similarly ambitious target (Fabic et al. 2015).

The key question is how to accomplish these goals. While numerous studies over decades have documented factors that contribute to unmet need, a recent study summarized the reasons using Demographic and Health Survey (DHS) data from 51 countries between 2006 and 2013 (Sedgh and Hussain 2014). Among the African countries included in the study, the most common reason for nonuse was concern about side effects or health complications. Such concerns accounted for 28 percent of nonuse in Africa, and a staggering 43 percent of nonuse in Kenya, where our study is based. An important limitation of that study (and of the DHS methodology on this topic) is that the category “side effects and health concerns” may encompass a wide range of factors, including scientifically established side effects of specific methods as well as various myths or misconceptions.

Qualitative studies in Kenya and elsewhere in the sub‐Saharan Africa region provide a modest amount of additional detail on what the category “side effects and health concerns” may include. One such factor is the belief that modern contraceptive use causes infertility. This is important to understand given that motherhood often defines a woman’s treatment in the community and infertility is seen as primarily a woman’s issue (Kimani and Olenja 2001; Hollos et al. 2009). Therefore, the destructive social consequences of infertility in sub‐Saharan Africa for women are immense (Donkor and Sandall 2007; Naab, Brown, and Heidrich 2013; Rouchou 2013). In qualitative studies in Ghana (Adongo et al. 2014; Hindin, McGough, and Adanu 2014), Kenya (Burke and Ambasa‐Shisanya 2011; Ochako et al. 2015), Madagascar (Klinger and Asgary 2017), Nigeria (Otiode, Oronsaye, and Okonofua 2001; Schwandt et al. 2015), Rwanda (Farmer et al. 2015), and Uganda (Morse et al. 2014), participants mentioned infertility along with other side effects as reasons for nonuse. In some cases, infertility is mentioned only briefly. Some studies, however, provide slightly more detail about the nature of this belief. In western Kenya, for example, Burke and Ambasa‐Shisanya (2011) documented the belief that infertility can occur as a result of extended (five years or longer) use of injectables. Others (Hindin, McGough, and Adanu 2014; Ochako et al. 2015) documented the belief that use of hormonal methods by young, nulliparous women is most likely to lead to infertility.

While prior qualitative studies have provided some detail on the nature of these beliefs, quantitative surveys provide some information about their prevalence. In a nationally representative sample in Nigeria, Ankomah, Anyanti, and Oladosu (2011) found that nearly one‐third agreed with the statement, “Family planning can lead to infertility in a woman.” Surveys in Kenya, Nigeria, and Senegal demonstrated that the percentage of women endorsing the belief that “Contraceptives can harm your womb” ranged from 62 percent in Kenya to 37 percent in Senegal (Gueye et al. 2015). Similar beliefs were also documented in a survey in northern Ethiopia (Gebremariam and Addissie 2014).

Addressing the belief that modern contraceptive use causes infertility may be an important component to increase uptake of contraception and to reduce unmet need. To be truly effective, however, these interventions must be informed by a deeper understanding of this belief. Providing this deeper examination of the belief that contraception causes infertility is the goal of this article. Drawing upon data from focus group discussions (FGDs) and key informant interviews (KIIs) conducted as part of a larger mixed‐methods study on social networks, social norms, and uptake of modern contraceptives in rural Kilifi County, Kenya we describe in greater detail prevailing beliefs about the link between modern contraceptive use and infertility. By connecting this belief to other themes in the data, we also provide some insight into how these beliefs may arise and spread, and into the factors that may make them salient to people in this and other sub‐Saharan African settings.

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